Gap Assessment Reporting Format

H o s p ita l & H e a lt h C a r e C o n s u lta n ts
REPORT 1
August 2009
GAP ANALYSIS REPORT

FOR
N A B H A C C R E D I T AT I O N P R O G R A M M E
OF
CLIENT
PREPARED BY
Astron Hospital and Health Care Consultants Pvt. Ltd.

Quality and Accreditation Division
Publication, reproduction, photocopying, storage, or transmission

electronically or otherwise, of all or any part of these documents without the
prior written permission from Astron Hospital and Health Care Consultants
Pvt. Ltd. New Delhi, India is strictly prohibited. It is illegal to make copies of
all or any part of these documents (whether internally or externally) without
the prior written permission of the copyright holder. For permission regarding
the use of all or any part of the documents, contact Astron Hospital and
Health Care Consultants Pvt. Ltd. New Delhi 91-11-42148131/32
0
Astron Hospital and Health Care
Gap Analysis Report
H o s p ita l & H e a lth C a r e C o n s u lt an ts
Consultants Pvt. Ltd., New Delhi
Soni Hospital
FOREWORD
Quality management system and the Accreditation process in compliance with standards, is a tool
for quality assurance and quality improvement for hospitals that in turn help ensure quality
healthcare services, standardized output, and aim for the best outcome possible. Spin offs of the
system include economy, effectiveness, leadership amongst peer institution, confidence of the
citizens in the establishment, and a culture of teamwork with a focus on service quality.
The Quality Council of India is an autonomous body under the Government of India, which has the
National Accreditation Board for Hospitals and Health Care Providers (NABH) amongst several
other boards under its fold. The NABH standards place emphasis on patient, staff, visitor and
environment safety, infection control, and quality of care. The standards are deceptively simple,
however whilst implementing them extra effort and resources will be required. Compliance will
more than compensate with the benefits that accrue, but it shall be remembered, that ‘Quality’,
like success, is a pathway, and not a destination.
With that Astron Hospital and Health Care Consultants Pvt. Ltd. wish the all the very best in their
voyage towards implementing the quality management system and accreditation of public hospitals
with the NABH.
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Soni Hospital
ACKNOWLEDGEMENT
Our heartfelt thanks to ………………………………….and the Governing Board members enabling

us to carry out National accreditation Board for Hospitals & Healthcare Providers accreditation
activity at their hospital. We feel privileged to be associated with this organization of repute and
being a part of the quality movement initiative taken up by its authorities
We are highly thankful to,…………………………………………… for providing us a platform to

initiate the accreditation activity and complete the first step that of gap assessment study in
We are profoundly grateful to,…………………………………………………… who has been very

supportive right from beginning. We are sure, that with able leadership of, the objective of
achieving quality standards of the level of accreditation norms will not be a distant dream.
We would like to thank, …………………………………………Medical Supdt, who has been

extremely cooperative and helped us in getting the gap assessment completed. His readiness for
taking up the core responsibility of coordinating and providing us with all necessary arrangement
required to complete the activity of Gap Assessment.
Our sincere thanks to Nursing Superintendent, and all HODs, in-charges and staff of the hospital,
who took out time from their very busy schedule, to interact with us and provide us with the
information required for this study. Needless to say that this activity would not have been
completed without their selfless contribution.
Lastly, we would like to thank all those whose names are not mentioned here but their contribution
to this study could not be undermined.
Astron Hospital and Health Care Consultants Pvt. Ltd.
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TABLE OF CONTENTS
Section No Topic Page Number

Foreword 1
Acknowledgement 2
Table of Contents 3
1. Introduction 4
2. Organization of report 5
3. Hospital Profile 7-13
4. Physical structure requirement 14 - 23
5. Gap assessment as per NABH standards 24 -127
6. Summary table of scores 128
7. Result of NABH gap assessment 129
Annexure
Annexure ‘A’ Signage & Displays 130-131
Annexure ‘B’ Physical Safety Requirements 132-133
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SECTION 1. INTRODUCTION
1. …………………………….is one of the finest medical institutions in North India. The hospital
is governed by ……………………………………………………
2. The philosophy with which the hospital has been incepted is provision of medical care to the
needy.
3. ……………….has taken up the initiative to standardize the patient care and its management
system and initiate an activity of continual quality improvement
4. With this thought has chosen ……………………..NABH accreditation norms as a reference
to improve and standardize the health care delivery in the hospital
5. Astron Hospital and Health Care Consultants Pvt. Ltd. is a consultancy firm providing
consultancy to all spheres of hospital planning and management. Quality and accreditation
division of the consultancy is well known to provide consultancy services to hospitals,
wanting to implement quality management and accreditation systems
6. Astron has been taken up by …………………….as consultant to provide the consultancy
services in planning and helping the hospital’s team in achieving NABH accreditation
7. As a first step of this project, detailed gap analysis has been carried out to identify the
existing status of infrastructure and processes vis-à-vis NABH standards requirement
8. This report is the deliverable of gap assessment study carried out at ……………………by
Astron Hospital and Health Care Consultant, with the help of hospital’s authorities and staff
9. The report details the subjective and objective evaluation and findings of infrastructure and
NABH standards related requirements
10. All findings and suggestions presented in this report is on the basis of primary visit made by
Astron Consultants and data and information provided by the hospital
11. It is to be noted that since evaluation of NABH standards implementation in a hospital is
partly subjective, difference in score calculated for NABH compliance may vary, in case
similar study is carried out by different consultant / assessor. The analysis has been done on
the basis of standardized checkpoints and our previous experience with other hospital’s
assessment. With this limitation, it is suggested that the score shall be used only to make a
mental picture of compliance level, while focusing on all systems and standards required for
NABH accreditation
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SECTION 2. ORGANISATION OF REPORT
 This report is intended to identify those structural requirements of quality management and accreditation,
which are cost intensive and takes long lead-time for addressing. Other than this a detailed gap
assessment with respect to every standards and objective elements of NABH – 2 nd edition has also been
carried out and presented in this report. The report has been prepared and submitted with the objective
of taking an early action on these gaps, so that they can be addressed within time before the hospital
applies for the accreditation pre-assessment.
 Following categories of gaps and requirements have been specified in this report
o Physical structure requirements
o Gap assessment as per NABH standards
 The report is organized in sections for specifying the aspects. Subsections are provided within sections,
wherever required. A brief profile of the hospital is also provided in to understand the status.
 Annexure are provided at the end of the report on those aspects that requires detailing and description. A
reference has been made in the main text wherever it has an annexure to be referred.
 The findings and requirements specified in this report have been prioritized as per their importance and
criticality, so that hospital can plan the action as per the resource availability and practicality aspects.
 It is emphasized that these requirements are important and should be actioned upon as early as
possible, so that the same can be fulfilled within the project time. Also many of the process related
aspects required for accreditation are dependent on fulfillment of infrastructural gaps. Thus, delay in
action on fulfilling these requirements will affect the implementation of processes and in turn
will delay the entire project time.
 It is suggested that hospital authorities read the report carefully and develop a plan of action to fulfill
these requirements.
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H o s p ita l & H e a lth C a r e C o n s u lt a n ts
Soni Hospital
SECTION 3. HOSPITAL PROFILE
S. No. Particulars Details

1.
Name of Hospital
2.
Ownership Type
3.
Address
a.for Communication
b.for locating Hospital
2.
Contact person:
(for correspondence and
liaison)
3.
Contact numbers: (land line
with area code and mobile)
4.
E-mail
5.
Date of establishment of
hospital
6.
Vision statement
7.
Mission statement:
8.
Any Quality certification or
Accreditation received by
the facility in past
11. Clinical services offered by the hospital Specialty(s):
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Specialties Number of specialist (full time) Number of specialist (visiting /

honorary)
Anesthesia
Cardiology
Cardiothoracic Surgery
Dentistry
Dermatology
ENT
Gastroenterology
General Medicine
GI Surgery
General surgery
Nephrology
Neurology
Neurosurgery
O&G
Ophthalmology
Orthopedic
Outreach Services
Pediatrics
Pediatric Surgery
Pathology
Physiotherapy
Plastic surgery
Psychiatry
Radio diagnosis
Rehab
Urology
Number of Non Specialist
doctors
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FACILITY DETAILS

1. Plot area
2. Total built-up area
3. Number of buildings
4. Number of floors
5. Number of Lifts
6. Number of ramps
BED DISTRIBUTION
1. Total number of complement beds (beds on which patients are kept overnight):
2. Total number of non-compliment beds:
S. No. Categories of beds Number of beds per Number of rooms
room
1. New Deluxe
2. Super Deluxe
3. Semi Deluxe
4. Male Private + NSR + SSR
5. Female Private
6 General Medical Ward
7 Urology Ward
8 Pediatric Ward
9 Gynae/ Maternity Ward
10 Transit Ward
11 Orthopedic Ward
12 Neuro Sciences Ward
13 Nephrology
14 Convalescent – I
15 Convalescent – II
16 Ophthalmology
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17 Day Care
18 Casualty
19 Neonatal
20 Semi Pvt.
21 Pre Operative
INTENSIVE CARE BEDS
S. No. Designation of ICU Number of beds per Number of

room rooms
1. Medical Intensive Care Unit
2. Surgical Cardiac Care Unit
3. Medical Cardiac Care Unit
4. Step down Intensive Care Unit
5. Paediatric Intensive Care Unit
6. Surgical Intensive Care Unit
7. Neuro Intensive Care Unit
8. Pre-mature Care Unit /
9. Intensive Pre-mature Unit
10
11
12
OPERATING SUITES
S. No. Designation of Operation theatre (Major and Number

Minor) and Endoscopy suites
1. Terrace Operation Theatre
2. New Operation Theatre
3. Old Operation Theatre
4. Endoscopy Room
5. Cath Lab
6. Dialysis
7. Labour Room
8. Transfusion Ward
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9. Emergency
10. Incomplete
11.
12.
HOSPITAL HUMAN RESOURCE
Staffing pattern
Staff category On hospital pay roll Contractual
Nursing Staff (category wise)

Nursing Superintendent
Deputy Nursing Superintendent
Asst. Nursing Superintendent
Sister Incharges
Acting Sister Incharges
Staff Nurses
Nursing Aid
Technical Staff (category wise)

Lab Technicians
OT Technicians
X-Ray Technicians
Perfusionist
Endoscopy
ECG Technicians
EEG Technicians
Technician (Nephrology)
Medical administration (category

wise)
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Senior Administrative Staff

Honorary Consultants
Resident
General administration (category

wise)
Senior Administrative staff
Maintenance
Ministerial
Housekeeping and security staff

(category wise)
Ward Boy
Ward Lady
Sweepers
Tech. Aid
Class IV (Contract)
Security (Contract)
DETAILS OF DIAGNOSTIC SERVICES
S. Diagnostic services
No.
Laboratory Medicine (Please list scope of services)
Bio-Chemistry
Pathology
Hematology
Micro-Biology & Serology
Histopathology
Cytopathology
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Imaging Sciences (Please list scope of services)

C-T
X-Ray
Ultra Sound
Special Diagnostics
EEG
Colour Doppler
ECG
Eco
TMT
Audiometery
SUPPORT SERVICES
S. Service category Available / Not available

No.
1.
Pharmacy
2. Blood Bank
3. Medical Record Department
4. CSSD
5. Piped medical gas system
6. Dietetics
Others
HIS & PACS
S. Administrative departments (please list)

No.
1. Accounts/ Finance (including IP billing)
2. HRD
3. Maintenance
4. Stores & Purchases
5. IT
6. PRO
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7. OPD, Reception & Enquiries

8. Medical Records
S. Outsourced services (please list)

No.
1. Security
2. Housekeeping
3. Kitchen
4. Laundry
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WORK LOAD DETAILS (of the current quarter)

IPD indices
1. Bed occupancy rate
2. Average length of stay
3. Average daily surgeries (major)
4. Average daily surgeries (minor)
5. Average daily deliveries
6. Average daily admissions
7. Average daily discharges
OPD indices
8. Average daily OPD attendance
9. Average daily new patients registration
10. Average daily follow up patients
11. Average daily day care patients
Emergency indices
12. Average daily emergency attendance
13. Average monthly emergency surgeries
Diagnostics
14. Average number of Laboratory tests per day
15. Average number of Radiological tests per day
Please provide following documents along with this profile (if convenient)
1. Architectural plan of the facility
2. List of Major equipments
3. Specialty / Department wise bed allocation (if applicable)
4. Last audited balance sheet
SECTION 4. PHYSICAL STRUCTURE REQUIREMENTS
This section identifies the structural deficiencies which may come across the quality management
requirements as expected by NABH standards. The findings are presented department wise and is
prioritized as per the necessity.
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Other than these structural deficiencies there are certain facility requirements that are necessary to
demonstrate a safe and secured hospital environment. This has been listed out in Annexure ‘B’
(V- Vital; E – Essential, D – Desirable; P - Priority
This classification is given for the hospital to prioritize their work and plan the scope of
improvement as per their resource availability and necessity)
S. No. Department and observations Desirabilit Priority
y
1. EMERGENCY WARD
1.1.
1.2.
1.3.
1.4.
1.5.
1.6.
1.7.
1.8.
2. IMAGING DEPARTMENT
2.1.
2.2.
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
3. INPATIENT DEPARTMENT
3.1.
3.1.1.
3.1.2.
3.1.3. Support Areas-.
Clean Utility –
Dirty Utility -.
Equipment Room –
Treatment Rooms –
Isolation Rooms -.
3.1.4.
3.1.5.
3.1.6. Resuscitation facility
3.2. Hand washing facilities
3.2.1. Electrical Backup -
3.3. PRIVATE WARDS
3.3.1.
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y
4. INTENSIVE CARE UNIT
4.1. .
4.2. Zoning-
4.3. The interbed distance
4.4. The Nursing Station
4.5. The ventilation.
5. DIALYSIS UNIT
5.1.
5.2. Zoning-.
5.3. The interbed distance
5.4.
5.5. The hand washing facilities
6. CSSD
6.1.
6.2.
6.3.
6.4.
7. OPERATION THEATRES
7.1. 
7.2.
7.3.
8. LABOR ROOMS
8.1. .
9. LABORATORY
9.1.
10. OPD
10.1.
10.2.
10.3.
10.4.
10.5.
11. LAUNDRY
11.1. 
12. MEDICAL RECORD DEPARTMENT
12.1. .
12.2. BIOMEDICAL WASTE MANAGEMENT
12.3.
13. PIPED MEDICAL GAS SYSTEM
13.1.
13.2.
14. SIGNAGES AND DISPLAYS
14.1.
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y
15. FIRE FIGHTING SYSTEM
15.1.
15.2.
15.3.
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SECTION 5: GAP ASSESSMENT AS PER NABH STANDARDS
Elements Observation Scores Recommendations

(0/ 5/ 10)
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)
AAC.1: The organization defines and displays the services that it can provide.
a The services being provided are

clearly defined and are in
consonance with the needs of
the community.
b The defined services are
prominently display.
c The staff is oriented to these

services.
Average Score
AAC.2: The organization has a well-defined registration and admission process.
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a. Standardized policies and

procedures are used for
registering and admitting patients
b. The policies and procedures

address out- patients, in-patients
and emergency patients
c. Patients are accepted only if the

organization can provide the
required service
d. The policies and procedures also

address managing patients
during non availability of beds.
e. The staff is aware of these

processes
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a. Policies guide the transfer of

unstable patients to another
facility in an appropriate
manner.
b. Policies guide the transfer of

stable patients to another
facility
c. Procedures identify staff

responsible during transfer
d. The organization gives a

summary of patient’s condition
and the treatment given
Average Score
AAC.4 During admission the patient and/ or family members are educated to make informed decision.
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a. The patients and/ or family

members are explained about
the proposed care.
b. The patients and/ or family
the expected results.
c. The patients and/ or family

the possible complications.
d. The patients and/ or family

the expected costs.
Average Score
AAC.5 Patients cared for by the organization undergo an established initial assessment.
a. The organization defines the

content of the assessments for
the out patients, in patients and
emergency patients.
b. The organization determines who
can perform the assessments.
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c. The organization defines the time

frame within which the initial
assessment is completed.
d. The initial assessment for in-

patients is documented within 24
hours or earlier as per the
patient's condition or hospital
policy.
e. Initial assessment includes
screening for nutritional needs.
f. The initial assessment results in

a documented plan of care
which is monitored.
g. The plan of care also includes

preventive aspects of care.
a. All patients are reassessed at

appropriate intervals.
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b. Staff involved in direct clinical

care document reassessments.
c. Patients are reassessed to

determine their response to
treatment and to plan further
treatment or discharge
Average Score
AAC.7 Laboratory services are provided as per the requirements of the patients.
a. Scope of the laboratory

services are commensurate to
the services provided by
organization
b. Adequately qualified and
trained personnel perform
and/or supervise the
investigations.
c. Policies and procedures guide
collection, identification,
handling, safe transportation,
processing and disposal of
specimens.
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d. Laboratory results are available

within a defined time frame.
e. Critical results are intimated

immediately to the concerned
personnel.
f. Laboratory tests not available
in the organization are
outsourced to organization(s)
based on their quality
assurance system.
Average Score
AAC.8 There is an established laboratory quality assurance programme.
a. The laboratory quality assurance

programme is documented.
b. The programme addresses
verification and validation of test
methods
c. The programme addresses
surveillance of test results
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d. The programme includes

periodic calibration and
maintenance of all equipments.
e. The programme includes the
documentation of corrective and
preventive actions
Average Score
AAC.9 There is an established laboratory safety programme.
a. The laboratory safety programme

is documented.
b. This programme is integrated

with the organization's safety
programme.
c. Written policies and procedures

guide the handling and disposal
of infectious and hazardous
materials.
d. Laboratory personnel are
appropriately trained in safe
practices.
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e. Laboratory personnel are

provided with appropriate safety
equipment/ devices.
Average Score
AAC.10 Imaging services are provided as per the requirement of the patients.
a. Imaging services comply with the

legal and other requirement.
b. Scope of the imaging services

are commensurate to the
services provided by the
organization.
c. Adequately qualified and trained
personnel perform, supervise
and interpret the investigations.
d. Policies and procedures guide

identification and safe
transportation of patients to
imaging services.
e. Imaging results are available
within a defined time frame.
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f. Critical results are intimated

immediately to the concerned
personnel.
g. Imaging tests not available in the
organization are outsourced to
organization(s) based on their
quality assurance system
Average Score
AAC.11 There is an established quality assurance programme for imaging services.
a. The quality assurance program

for imaging services is
documented.
b. The programme addresses
verification and validation of
imaging methods.
c. The programme addresses
surveillance of imaging results.
d. The programme includes
periodic calibration and
maintenance of all equipments.
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e. The programme includes the

documentation of corrective and
preventive actions
Average Score
AAC.12 There is an established radiation safety programme.
a. The radiation safety programme
is documented.
b. This programme is integrated

with the organization’s safety
programme
c. Written policies and procedures

guide the handling and disposal
of radio-active and hazardous
materials.
d. Imaging personnel are provided
with appropriate radiation safety
devices
e. Radiation safety devices are
periodically tested and
documented
f. Imaging personnel are trained in
radiation safety measures
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g. Imaging signage are prominently

displayed in all appropriate
locations
h. Policies and procedures guide
the safe use of radioactive
isotopes for imaging services.
Average Score
AAC.13 Patient care is continuous and multidisciplinary in nature.
a. During all phases of care, there

is a qualified individual identified
as responsible for patient’s care.
b. Care of patients is coordinated in

all care setting within the
organization.
c. Information about the patient's
care and response to treatment
is shared among medical,
nursing and other care providers.
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d. Information is exchanged and

documented during each staffing
shift, between shifts, and during
transfers between units/
departments.
e. The patient’s record(s) is
available to authorized care
providers to facilitated the
exchange of information.
f. Policies and procedures guide
the referral of patients to other
departments/ specialties.
Average Score
AAC.14 The organization has a documented discharge process.
a. The patient’s discharge process

is planned in consultation with
the patient and/or family
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b. Policies and procedures exist for

coordination of various
departments and agencies
involved in the discharge process
(including medico-legal cases)
c. Policies and procedures are in

place for patients leaving against
medical advice
d. A discharge summary is given to

all the patients leaving the
organization (including patients
leaving against medical advice)
Average Score
AAC.15 Organization define the content of the discharge summary.
a. Discharge summary is provided

to the patients at the time of
discharge.
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b. Discharge summary contains the

reasons for admission, significant
findings and diagnosis and the
patient’s condition at the time of
discharge.
c. Discharge summary contains

information regarding
investigation results, any
procedure performed, medication
and other treatment given.
d. Discharge summary contains

follow up advice, medication and
other instructions in an
understandable manner.
e. Discharge summary incorporates
instructions about when and how
to obtain urgent care.
f. In case of death the summary of
the case also includes the cause
of death.
Average Score
Total Score
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Chapter 2: CARE OF PATIENTS (COP)

COP.1: Uniform care of patients is provided in all settings of the organization and is
guided by the applicable laws, regulations and guidelines.
a Care delivery is uniform when

similar care is provided in more
than one setting
b Uniform care is guided by
policies and procedures which
reflect applicable laws and
regulations.
c The care and treatment orders
are signed, named, timed and
dated by the concerned doctor.
d The care plan is countersigned

by the clinician in-charge of the
patient within 24 hours.
e Evidence based medicine and

clinical practice guidelines are
adopted to guide patient care
whenever possible.
Average Score
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COP.2: Emergency services are guided by policies, procedures and applicable laws and
regulations.
a Policies and procedure for

emergency care are
documented.
b Policies also address handling of
medico-legal cases
c The patient receives care in

consonance with the policies.
d Policies and procedures guide

the triage of patients for initiation
of appropriate care.
e Staff is familiar with the policies
and trained on the procedures for
care of emergency patients.
f Admission or discharge to home

or transfer to another
organization is also documented.
Average Score
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COP.3: The ambulance services are commensurate with the scope of the services provided by the organizations.
a There is adequate access and

space for the ambulance(s).
b Ambulance(s) is appropriately
equipped.
c Ambulance(s) is manned by the

trained personnel
d There is a checklist of all medical
equipment and emergency
medications.
e Equipment are checked on a
daily basis.
f Emergency medications are

checked daily and prior to
dispatch.
g The ambulance(s) has a proper
communication system.
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Average Score
COP.4: Policies and procedures guide the care of patients requiring cardio-pulmonary
resuscitations.
a Documented policies and

procedures guide the uniform
use of resuscitation throughout
the organization.
b Staff providing direct patient care
is trained and periodically update
in cardio pulmonary
resuscitations.
c The events during a cardio

pulmonary resuscitation are
recorded.
d A post-event analysis of all

cardiac asserts is done by a
multidisciplinary committee.
e Corrective and preventive
measures are taken based on
the post-event analysis.
Average Score
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COP.5: Policies and procedures define rational use of blood and blood products.

procedures are used to guide
rational use of blood and blood
products
b The transfusion services are
governed by the applicable laws
and regulations.
c Informed consent is obtained for

donation and transfusion of blood
and blood products
d Informed consent also includes
patient and family education
about donation.
e Staff is trained to implement the
policies.
f Transfusion reactions are
analyzed for preventive and
corrective actions.
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a The organization has

documented admission and
discharge criteria for its intensive
care and high dependency units.
b Staff is trained to apply these

criteria
c Adequate staff and equipment
are available
d Defined procedures for situation

of bed shortages are followed.
e Infection control practices are

followed
f A quality assurance programme
is implemented
Average Score
COP.7: Policies and procedures guide the care of vulnerable patients (elderly, physically and/ or mentally challenged and
children).
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a Policies and procedures are

documented and are in
accordance with the prevailing
laws and the national and
international guidelines.
b Care is organized and delivered
in accordance with the policies
and procedures.
c The organization provides for a

safe and secure environment for
this vulnerable group.
d A documented procedure exists

for obtaining informed consent
from the appropriate legal
representative.
e Staff is trained to care for this
vulnerable group.
Average Score
COP.8: Policies and procedures guide the care of high-risk obstetrical patients.
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a The organization defines and

displays whether high-risk
obstetric care can be cared for or
not.
b Persons caring for high-risk
obstetric cases are competent
c High-risk obstetric patient’s

assessment also includes
maternal nutrition.
d The organization caring for high

risk obstetric cases has the
facilities to take care of neonates
of such cases.
Average Score
COP.9: Policies and procedures guide the care of paediatric patients.

displays the scope of its
paediatric services
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b The policy for care of neonatal

patients is in consonance with
the national/ international
guidelines
c Those who care for children have

age specific competency
d Provisions are made for special

care of children.
e Patient assessment includes

detailed nutritional, growth,
psychosocial and immunization
assessment.
f Policies and procedures prevent

child/ neonates abduction and
abuse.
g The children’s family members
are educated about nutrition,
immunizations and safe
parenting and this is documented
in the medical record.
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Average Score
COP.10: Policies and procedures guide the care of patients undergoing moderate
sedation.
a Competent and trained persons
perform sedation.
b The person administrating and

monitoring sedation is different
from the person performing the
procedure.
c Intra – procedure monitoring
includes at a minimum the heart
rate, cardiac rhythm, respiratory
rate, blood pressure, and oxygen
saturation, and level of sedation.
d Patients are monitored after

sedation.
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e Criteria are used to determine

appropriateness of discharge
from the recovery area.
f Equipment and manpower are

available to rescue patients from
a deeper level of sedation than
that intended.
Average Score
COP.11: Policies and procedures guide the administration of anesthesia.
a There is a documented policy

and procedure for the
administration of anesthesia
b Pre anaesthesia assessment is
done for all patients who undergo
anaesthesia administration.
c The pre-anesthesia assessment

results in formulation of an
anesthesia plan which is
documented
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d An immediate preoperative
reevaluation is documented
e Informed consent for

administration of anesthesia is
obtained by the anesthetist
f During anesthesia monitoring
includes regular and periodic
recording of heart rate, cardiac
rhythm, respiratory rate, blood
pressure, oxygen saturation,
airway security and patency and
level of anesthesia
g Each patient’s post-anesthesia

status is monitored and
documented
h A qualified individual applies

defined criteria to transfer the
patient from the recovery area
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i All adverse anesthesia events

are recorded and monitored
Average Score
COP.12: Policies and procedures guide the care of patients undergoing surgical
procedures.
a The policies and procedures are
documented
b Surgical patients have

preoperative assessment and a
provisional diagnosis
documented prior to surgery.
c An informed consent is obtained
by the surgeon prior to the
procedure.
d Documented policies and
procedure exist to prevent
adverse events like wrong site,
wrong patients and wrong
surgery.
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e Persons qualified by law are

permitted to perform the
procedures that they are entitled
to perform.
f A brief operative note is
documented prior to transfer out
of patients from recovery area.
g The operating surgeons

documents the post operative
plan of care
h A quality assurance programme
is followed for the surgical
services
i The quality assurance program
includes surveillance of the
operation theatre environment
j The plan also includes

monitoring of surgical site
infection rates
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procedures guide the care of
patients under restraints
b These include both physical and

chemical restraint measures
c These include documentation of

reasons for restraints
d These patients are more

frequently monitored
e Staff receive training and periodic
updating in control and restraint
techniques
Average Score
COP.14: Policies and procedures guide appropriate pain management.
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procedures guide the
management of pain.
b The organization respects and

supports the appropriate
assessment and management of
pain for all patients
c Patient and family are educated
on various pain management
techniques
Average Score
COP.15: Policies and procedures guide appropriate rehabilitative services.

procedures guide the provision of
rehabilitative services
b These services are

commensurate with the
organizational requirements
c Rehabilitative services are

provided by a multidisciplinary
team
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Average Score
COP.16: Policies and procedures guide all research activities.

procedures guide all research
activities in compliance with
national and international
guidelines
b The organization has an ethics
committee to oversee all
research activities
c The committee has the powers to

discontinue a research trial when
risks outweigh the potential
benefits
d Patient’s informed consent is
obtained before entering them in
research protocols
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e Patients are informed of their

right to withdraw from the
research at any stage and also of
the consequences (if any) of
such withdrawal
f Patients are assured that their
refusal to participate or
withdrawal from participation will
not compromise their access to
the organization’s services
Average Score
COP.17: Policies and procedures guide nutritional therapy.

procedures guide nutritional
assessment and reassessment
b Patients receive food according

to their clinical needs
c There is a written order for the

diet
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d Nutritional therapy is planned

and provided in a collaborative
manner
e When families provide food, they
are educated about the patients
diet limitations
f Food is prepared, handled,
stored and distributed in a safe
manner
Average Score
COP.18: Policies and procedures guide the end of life care.

procedures guide the end of life
care
b These policies and procedures
are in consonance with the legal
requirements
c These also address the

identification of the unique needs
of such patient and family
d These also include sensitively
addressing issues such as
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autopsy and organ donation
e Staff is educated and trained in

end of life care
Average Score
Total Score
Chapter 3: MANAGEMENT OF MEDICATION (MOM)
MOM.1: Policies and procedures guide the organization of pharmacy services and
usage of medication.
a There is a documented policy

and procedure for pharmacy
services and medication usage
b These comply with the applicable

laws and regulations
c A multidisciplinary committee
guides the formulation and
implementation of these policies
and procedures
Average Score
MOM.2: There is a hospital formulary.
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a A list of medication appropriate

for the patients and
organization’s resources is
developed
b The list is developed
collaboratively by the
multidisciplinary committee
c There is a defined process for
acquisition of these medications
d There is a process to obtain

medications not listed in the
formulary
Average Score
MOM.3: Policies and procedures exist for storage of medication.

procedures exist for storage of
medication
b Medications are stored in a
clean, well lit and ventilated
environment
c Sound inventory control practices
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guide storage of the medications
d Medications are protected from

loss or theft.
e Sound alike and look alike

medications are stored
separately
f There is a method to obtain
medication when the pharmacy
is closed
g Emergency medications are
available all the time
h Emergency medications are
replenished in a timely manner
when used
Average Score
MOM.4: Policies and procedures exist for prescription of medications.

procedures exist for prescription
of medications
b The organization determines who
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can write orders

c Orders are written in a uniform
location in the medical records
d Medication orders are clear,

legible, dated, timed, named and
signed
e Policy on verbal orders is
documented and implemented
f The organization defines a list of

high risk medication
g High risk medication orders are

verified prior to dispensing
Average Score
MOM.5: Policies and procedures guide the safe dispensing of medications.

procedures guide the safe
dispensing of medications
b The policies include a procedure
for medication recall
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c Expiry dates are checked prior to

dispensing
d Labeling requirements are

documented and implemented by
the organization
Average Score
MOM.6: There are defined procedures for medication administration.
a Medications are administered by

those who are permitted by law
to do so
b Prepared medication are labeled
prior to preparation of a second
drug
c Patient is identified prior to
administration
d Medication is verified from the
order prior to administration
e Dosage is verified from the order
prior to administration
f Route is verified from the order
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g Timing is verified from the order

h Medication administration is
documented
i Polices and procedures govern
patient’s self administration of
medications
j Polices and procedures govern
patient’s medications brought
from outside the organization.
Average Score
MOM.7: Patients and family members are educated about safe medication and food-drug interactions.
a Patient and family are educated

about safe and effective use of
medication
b Patient and family are educated

about food-drug interactions
Average Score
MOM.8: Patients are monitored after medication administration.
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a Patients are monitored after

medication administration and
this is documented
b Adverse drug events are defined
c Adverse drug events are

reported within a specified time
frame
d Adverse drug events are
collected and analyzed
e Policies are modified to reduce
adverse drug events when
unacceptable trends occur
Average Score
MOM.9: Policies and procedures guide the use of narcotic drugs and psychotropic
substances.
procedures guide the use of
narcotic drugs and psychotropic
substances
b These policies are in
consonance with local and
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national regulations
c A proper record is kept of the
usage, administration and
disposal of these drugs
d These drugs are handled by
appropriate personnel in
accordance with policies
Average Score
MOM.10: Policies and procedures guide the usage of chemotherapeutic agents.

procedures guide the usage of
chemotherapeutic agents
b Chemotherapy is prescribed by
those who have the knowledge
to monitor and treat the adverse
effect of chemotherapy
c Chemotherapy is prepared and
administered by qualified
personnel
d Chemotherapy drugs are

disposed off in accordance with
legal requirements
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Average Score
MOM.11: Policies and procedures govern usage of radioactive drugs.

procedures govern usage of
radioactive drugs.
b These policies and procedures
are in consonance with laws and
regulations
c The policies and procedures
include the safe storage,
preparation, handling, distribution
and disposal of radioactive drugs
d Staff, patients and visitors are

educated on safety precautions

procedures govern procurement
and usage of implantable
prosthesis
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b Selection of implantable
prosthesis is based on scientific
criteria and
national/internationally
recognized approvals
c The batch and serial number of
the implantable prosthesis are
recorded in the patient’s medical
record and the master logbook.
Average Score
MOM.13: Policies and procedures guide the use of medical gases.

procedures govern procurement,
handling, storage, distribution,
usage and replenishment of
medical gases.
b The policies and procedures
address the safety issues at all
levels
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c Appropriate records are

maintained in accordance with
the policies, procedures and
legal requirements
Average Score
Total Score
Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)
PRE.1: The organization protects patient and family right during care and informs them
about their responsibilities.
a Patient and family rights and

responsibilities are documented.
b Patients and families are

informed of their rights and
responsibilities in a format and
language that they can
understand.
c The organization’s leaders
protect patient's and family
rights.
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d Staff is aware of their

responsibility in protecting
patients and family rights
e Violation of patient and family
rights is recorded, reviewed and
corrective/ preventive measures
taken
Average Score
PRE.2: Patient and family rights support individual beliefs, values and involve the
patient and family in decision-making processes.
a Patient and family rights address

any special preferences, spiritual
and cultural needs.
b Patient and family rights include
respect for personal dignity and
privacy during examination,
procedures and treatment.
c Patient and family rights include

protection from physical abuse
and neglect.
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d Patient and family rights include

treating patient information as
confidential.
e Patient and family rights include
refusal of treatment.
f Patient and family rights include

informed consent before
anaesthesia, blood and blood
product transfusions and any
invasive/ high-risk procedures/
treatment.
g Patient and family right include
information and consent before
any research protocol is
initiated.
h Patient and family rights include
information on how to voice a
complaint.
i Patient and family rights include
information on the expected cost
of the treatment.
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j Patient and family has a right to

have an access to his/ her
clinical records.
Average Score
PRE.3: A Documented process for obtaining patient and / or families consent exists for
informed decision making about their care.
a General consent for treatment is

obtained when the patient enters
the organization.
b Patient and / or his family
members are informed of the
scope of such general consent.
c The organization has listed

those situations where informed
consent is required.
d Informed consent includes
information on risks , benefits,
alternatives and as to who will
perform the requisite procedure
in a language that they can
understand.
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e The policy describes who can

give consent when patient is
incapable of independent
decision-making.
Average Score
PRE.4: Patient and families have a right to information and education about their health
care needs.
a When appropriate, patient and

families and are educated about
the safe and effective use of
medication and the potential
side effects of the medication.
b Patient and families are

educated about diet and
nutrition.
c Patient and families are

educated about immunizations.
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d Patient and families are

educated about their specific
disease process, complications
and prevention strategies.
e Patient and families are
educated about preventing
infections.
f Patients and family are taught in
a language and format that they
can understand.
Average Score
PRE.5: Patient and families have a right to information on expected costs.
a There is uniform pricing policy in

a given setting (out-patient and
ward category)
b The tariff list is available to
patients.
c Patients and family are educated

about the estimated cost of
treatment.
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d Patients and family are educated

about the financial implications
when there is a change in the
patient condition or treatment
setting.
Average Score
Total Score
Chapter 5: HOSPITAL INFECTION CONTROL (HIC)
HIC.1: The organization has a well-designed, comprehensive and coordinated infection
control programme aimed at reducing/ eliminating risks to patients, visitors and
providers of care.
a The hospital infection control

programme is documented
which aims at preventing and
reducing risk of nosocomial
infections.
b The hospital has a multi-
disciplinary infection control
committee.
c The hospital has an infection
control team.
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d The hospital has designated and

qualified infection control
nurse(s) for this activity.
Average Score
HIC.2: The organization has an infection control manual, which is periodically updated.
a The manual identifies the

various high-risk areas &
procedures.
b It outlines methods of
surveillance in the identified
high-risk areas.
c It focuses on adherence to
standard precautions at all times
d Equipment cleaning and

sterilisation practices are
included.
e An appropriate antibiotic policy
is established and implemented
f Laundry and linen management

processes are also included.
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g Kitchen sanitation and food

handling issues are included in
the manual
h Engineering controls to prevent
infections are included
i Mortuary practices and

procedures are included as
appropriate to the organization.
j The organization defines the

periodicity of updating the
infection control manual
Average Score
HIC.3: The infection control team is responsible for surveillance activities in identified
areas of the hospital.
a Surveillance activities are

appropriately directed towards
the identified high-risk areas
b Collection of surveillance data is
an ongoing process
c Verification of data is done on

regular basis by the infection
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control team
d In cases of notifiable diseases,

information (in relevant format)
is sent to appropriate authorities.
e Scope of surveillance activities

incorporates tracking and
analyzing of infection risks, rates
and trends.
f Surveillance activities include

monitoring the effectiveness of
housekeeping services.
a The organization monitors

urinary tract infections.
b The organization monitors
respiratory tract infections.
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c The organization monitors intra-

vascular device infections
d The organization monitors

surgical site infections.
e Appropriate feedback regarding
HAI rates are provided on a
regular basis to medical and
nursing staff.
Average Score
HIC.5: Proper facilities and adequate resources are provided to support the infection
control programme.
a Hand washing facilities in all

patient care areas are
accessible to health care
providers.
b Compliance with proper hand
washing is monitored regularly.
c Isolation/ barrier nursing facilities

are available.
d Adequate gloves, masks, soaps,
and disinfectants are available
and used correctly.
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Average Score
HIC.6: The organization takes appropriate actions to control outbreaks of infections.
a Hospital has a documented

procedure for handling such
outbreaks.
b This procedure is implemented
during outbreaks.
c After the outbreak is over

appropriate corrective actions
are taken to prevent recurrence.
Average Score
HIC.7: There are documented procedures for sterilization activities in the organization.
a There is adequate space

available for sterilization
activities
b Regular validation tests for
sterilization are carried out and
documented
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c There is an established recall

procedure when breakdown in
the sterilization system is
identified.
Average Score
HIC.8: Statutory provisions with regard to Bio-medical Waste (BMW) management are
complied with
a The hospital is authorized by

prescribed authority for the
management and handling of
Bio-medical Waste.
b Proper segregation and
collection of Bio-medical Waste
from all patient care areas of the
hospital is implemented and
monitored
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c The organization ensures that

Bio-medical Waste is stored and
transported to the site of
treatment and disposal in proper
covered vehicles within
stipulated time limits in a secure
manner.
d Bio-medical Waste treatment
facility is managed as per
statutory provisions (if in-house)
or outsourced to authorized
contractor(s).
e Requisite fees, documents and
reports are submitted to
competent authorities on
stipulated dates.
f Appropriate personal protective
measures are used by all
categories of staff handling Bio-
medical Waste.
Average Score
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HIC.9: The infection control programme is supported by the organization's management and includes training of staff and
employee health.
a Hospital management makes

available resources required for
the infection control programme.
b The hospital regularly earmarks

adequate funds from its annual
budget in this regard.
c It conducts regular pre-induction

training for appropriate
categories of staff before joining
concerned department(s).
d It also conducts regular “in-
service” training sessions for all
concerned categories of staff at
least once in a year.
e Appropriate pre and post
exposure prophylaxis is provided
to all concerned staff members
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a The quality improvement

programme is developed,
implemented and maintained by
a multi-disciplinary committee.
b The quality improvement
programme is documented.
c There is a designated individual

for coordinating and
implementing the quality
improvement programme
d The quality improvement

programme is comprehensive
and covers all the major
elements related to quality
assurance and risk
management.
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e The designated programme is

communicated and coordinated
amongst all the employees of
the organization through proper
training mechanism.
f The quality improvement

programme is reviewed at
predefined intervals and
opportunities for improvement
are identified.
g The quality improvement
programme is a continuous
process and updated at least
once in a year.
Average Score
CQI.2: The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as
tools for continual improvement.
a Monitoring includes appropriate

patient assessment.
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b Monitoring includes safety and

quality control programmes of
diagnostics services.
c Monitoring includes all invasive
procedures
d Monitoring includes adverse
drug events.
e Monitoring includes use of
anesthesia.
f Monitoring includes use of blood
and blood products.
g Monitoring includes availability
and content of medical records.
h Monitoring includes infection
control activities.
i Monitoring includes clinical
research.
j Monitoring includes data
collection to support further
improvements
k Monitoring includes data
collection to support evaluation
of these improvements
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Average Score
CQI.3: The organization identifies key indicators to monitor the managerial structures,
processes and outcomes which are used as tools for continual improvement..
a Monitoring includes procurement

of medication essential to meet
patient needs.
b Monitoring includes reporting of
activities as required by laws
and regulations.
c Monitoring includes risk
management.
d Monitoring includes utilisation of
space, manpower and
equipment.
e Monitoring includes patient
satisfaction which also
incorporates waiting time for
services.
f Monitoring includes employee
satisfaction
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g Monitoring includes adverse

events and near misses.
h Monitoring includes data

collection to support further
study for improvements.
i Monitoring includes data
collection to support evaluation
of the improvements
Average Score
CQI.4: The quality improvement programme is supported by the management.
a Hospital Management makes

available adequate resources
required for quality improvement
programme.
b Hospital earmarks adequate
funds from its annual budget in
this regard.
c Appropriate statistical and
management tools are applied
whenever required.
Average Score
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CQI.5: There is an established system for audit of patient care services.
a Medical and nursing staff

participates in this system.
b The parameters to be audited
are defined by the organization
c Patient and staff anonymity is
maintained.
d All audits are documented.
e Remedial measures are
implemented.
Average Score
CQI.6: Sentinel events are intensively analyzed.
a The organization has defined
sentinel events.
b The organization has
established processes for
intense analysis of such events.
c Sentinel events are intensively
analyzed when they occur
d Corrective and preventive

Actions are taken based on the
findings of such analysis.
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Average Score
Total Score
Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)
ROM.1: The responsibilities of the management are defined.
a Those responsible for

governance lay down the
organization’s mission statement
b Those responsible for

governance lay down the
strategic and operational plans
commensurate to the
organization’s mission in
consultation with the various
stake holders.
c Those responsible for
governance approve the
organization’s budget and
allocate the resources required
to meet the organization’s
mission.
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d Those responsible for

governance monitor and
measure the performance of the
organization against the stated
mission
e Those responsible for
governance establish the
organization’s organogram.
f Those responsible for

governance appoint the senior
leaders in the organization.
g Those responsible for
governance support research
activities and quality
improvement plans.
h The organization complies with
the laid down and applicable
legislations and regulations
i Those responsible for
governance address the
organization’s social
responsibility
Average Score
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ROM.2: The services provided by each department are documented.
a Each organizational program,

service, site or department has
effective leadership
b Scope of services of each
department is defined.
c Administrative policies and
procedures for each department
is maintained.
d Departmental leaders are
involved in quality improvement.
Average Score
ROM.3: The organization is managed by the leaders in an ethical manner.
a The leaders make public the

mission statement of the
organization
b The leaders establish the
organization’s ethical
management
c The organization discloses its
ownership
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d The organization honestly

portrays the services which it
can and cannot provide
e The organization honestly
portrays its affiliations and
accreditation
f The organization accurately bills
for it’s services based upon a
standard billing tariff.
Average Score
ROM.4: A suitably qualified and experienced individual heads the organization.
a The designated individual has

requisite and appropriate
administrative qualifications
b The designated individual has
requisite and appropriate
administrative experience
Average Score
ROM.5: Leaders ensure that patient safety aspects and risk management issues are an
integral part of patient care and hospital management.
a The organization has an

interdisciplinary group assigned
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to oversee the hospital wide

safety programme
b The scope of the programme is
defined to include adverse
events ranging from “no harm” to
“sentinel events”.
c Management ensures
implementation of systems for
internal and external reporting of
system and process failures
d Management provides resources
for proactive risk assessment
and risk reduction activities.
Average Score
Total Score
Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)
FMS.1: The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility
inspection requirements.
a The management is conversant

with the laws and regulations
and knows their applicability to
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the organization
b Management regularly updates

any amendments in the
prevailing laws of the land.
c The management ensures
implementation of these
requirements.
d There is a mechanism to
regularly update licenses/
registrations/certifications.
Average Score
FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.
a There is a documented
operational and maintenance
(preventive and breakdown)
plan.
b Up-to-date drawings are
maintained which detail the site
layout, floor plans and fire
escape routes.
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c There is internal and external

sign posting in the organization
in a language understood by
patient, families and community.
d The provision of space shall be
in accordance with the available
literature on good practices
(Indian or International
Standards) and directives from
government agencies
e There are designated individuals
responsible for the maintenance
of all the facilities
f Maintenance staff is contactable
round the clock for emergency
repairs.
g Response times are monitored
from reporting to inspection and
implementation of corrective
actions.
Average Score
FMS.3: The organization has a program for clinical and support service equipment
management.
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a The organization plans for

equipment in accordance with its
services and strategic plan
b Equipment is selected by a
collaborative process.
c All equipment is inventoried and
proper logs are maintained as
required.
d Qualified and trained personnel
operate and maintain the
equipment.
e Equipment are periodically
inspected and calibrated for their
proper functioning
f There is a documented
operational and maintenance
(preventive and breakdown) plan
Average Score
FMS.4: The organization has provisions for safe water, electricity, medical gases and
vacuum systems.
a Potable water and electricity are

available round the clock.
b Alternate sources are provided
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for in case of failure.

c The organization regularly tests
the alternate sources.
d There is a maintenance plan for
piped medical gas, compressed
air and vacuum installation
Average Score
FMS.5: The organization has plans for fire and non-fire emergencies within the
facilities.
a The organization has plans and
provisions for early detection,
abatement and containment of
fire and non-fire emergencies.
b The organization has a

documented safe exit plan in
case of fire and non-fire
emergencies
c Staff is trained for their role in
case of such emergencies.
d Mock drills are held at least
twice in a year
Average Score
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FMS.6: The organization has a smoking limitation policy

implements its polices to reduce
or eliminate smoking
b The policy has provisions for
granting exceptions for patients
and families to smoke
Average Score
FMS.7: The organization plans for handling community emergencies, epidemics and
other disasters.
a The hospital identifies potential

emergencies.
b The organization has a
documented disaster
management plan.
c Provision is made for availability
of medical supplies, equipment
and materials during such
emergencies.
d Hospital staff is trained in the
hospital’s disaster management
plan
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e The plan is tested at least twice

in a year.
Average Score
FMS.8: The organization has a plan for management of hazardous materials
a Hazardous materials are

identified within the organization
b The hospital implements
processes for sorting, handling,
labelling, storage, transporting
and disposal of hazardous
material.
c Requisite regulatory
requirements are met in respect
of radioactive materials
d There is a plan for managing
spills of hazardous materials
e Staff is educated and trained for
handling such materials.
Average Score
FMS.9: The organization has system in place to provide a safe and secure environment
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a The hospital has a safety

committee to identify the
potential safety and security
risks
b This committee coordinates
development, implementation,
and monitoring of the safety plan
and policies.
c Patient safety devices are
installed across the organization
and inspected periodically.
d Facility inspection rounds to
ensure safety are conducted at
least twice in a year in patient
care areas and at least once in a
year in non-patient care areas.
e Inspection reports are
documented and corrective and
preventive measures are
undertaken.
f There is a safety education
programme for all staff.
Average Score
94
Gap Analysis Report
Soni Hospital
Total Score
Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)
HRM.1: The organization has a documented system of human resource planning.
a The organization maintains an

adequate number and mix of
staff to meet the care, treatment
and service needs of the patient.
b The required job specifications
and job description are well
defined for each category of
staff.
c The organization verifies the
antecedents of the potential
employee with regards to
criminal/negligence background.
Average Score
HRM.2: The staff joining the organization is socialized and oriented to the hospital
environment.
a Each staff member, employee,

student and voluntary worker is
appropriately oriented to the
95
Gap Analysis Report
Soni Hospital
organization’s mission and

goals.
b Each staff member is made
aware of hospital wide policies
and procedures as well as
relevant department / unit /
service / programme’s policies
and procedures.
c Each staff member is made
aware of his/her rights and
responsibilities.
d All employees are educated with
regard to patients’ rights and
responsibilities.
e All employees are oriented to
the service standards of the
organization.
Average Score
HRM.3: There is an ongoing programme for professional training and development of
the staff.
a A documented training and
development policy exists for the
staff.
96
Gap Analysis Report
Soni Hospital
b Training also occurs when job

responsibilities change/ new
equipment is introduced
c Feedback mechanisms for

assessment of training and
development programme exist.
Average Score
HRM.4: Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety.
a All staff is trained on the risks

within the hospital environment.
b Staff members can demonstrate
and take actions to report,
eliminate / minimize risks.
c Staff members are made aware
of procedures to follow in the
event of an incident.
d Reporting processes for
common problems, failures and
user errors exist
Average Score
97
Gap Analysis Report
Soni Hospital
HRM.5: An appraisal system for evaluating the performance of an employee exists as

an integral part of the human resource management process.
a A well-documented
performance appraisal system
exists in the organization.
b The employees are made

aware of the system of
appraisal at the time of
induction.
c Performance is evaluated
based on the performance
expectations described in job
description
d The appraisal system is used
as a tool for further
development.
e Performance appraisal is
carried out at pre defined
intervals and is documented.
Average Score
HRM.6: The organization has a well-documented disciplinary procedure.
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Gap Analysis Report
Soni Hospital
a A written statement of the

policy of the organization with
regard to discipline is in place.
b The disciplinary policy and
procedure is based on the
principles of natural justice.
c The policy and procedure is

known to all categories of
employees of the organization.
d The disciplinary procedure is in
consonance with the prevailing
laws.
e There is a provision for
appeals in all-disciplinary
cases.
Average Score
HRM.7: A grievance handling mechanism exists in the organization.
a The employees are aware of

the procedure to be followed in
case they feel aggrieved.
b The redress procedure
addresses the grievance.
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Gap Analysis Report
Soni Hospital
c Actions are taken to redress

the grievance.
Average Score
HRM.8: The organization addresses the health needs of the employees.
a A pre-employment medical
examination is conducted on
all the employees.
b Health problems of the
employees are taken care of in
accordance with the
organization’s policy.
c Regular health checks of staff
dealing with direct patient care
are done at-least once a year
and the findings/ results are
documented.
d Occupational health hazards
are adequately addressed.
Average Score
HRM.9: There is a documented personal record for each staff member.
a Personal files are maintained
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Gap Analysis Report
Soni Hospital
in respect of all employees.

b The personal files contain
personal information regarding
the employees qualification,
disciplinary background and
health status
c All records of in-service
training and education are
contained in the personal files
d Personal files contain result of
all evalutions.
Average Score
HRM.10: There is a process for collecting, verifying and evaluating the credentials
(education, registration, training and experience) of medical professionals permitted to
provide patient care without supervision.
a Medical professionals
permitted by law, regulation
and the hospital to provide
patient care without
supervision is identified.
101
Gap Analysis Report
Soni Hospital
b The education, registration,

training and experience of the
identified medical
professionals is documented
and updated periodically.
c All such information pertaining
to the medical professionals is
appropriately verified when
possible.
Average Score
HRM.11: There is a process for authorising all medical professionals to admit and treat patients and provide other clinical
services commensurate with their qualifications.
a Medical professionals admit
and care for patients as per the
laid down policies and
authorisation procedures of the
organization.
b The services provided by the
medical professionals are in
consonance with their
qualification, training and
registration.
102
Gap Analysis Report
Soni Hospital
c The requisite services to be

provided by the medical
professionals are known to
them as well as the various
departments/ units of the
hospital.
Average Score
HRM.12: There is a process for collecting, verifying and evaluating the credentials (education, registration, training and
experience) of nursing staff.
a The education, registration,

training and experience of
nursing staff is documented
and updated periodically.
b All such information pertaining
to the nursing staff is
appropriately verified when
possible.
Average Score
HRM.13: There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members
commensurate with their qualifications and any other regulatory requirements.
a The clinical work assigned to
nursing staff is in consonance
103
Gap Analysis Report
Soni Hospital
with their qualification, training

and registration.
b The services provided by
nursing staff are in accordance
with the prevailing laws and
regulations.
c The requisite services to be
provided by the nursing staff are
known to them as well as the
various departments / units of
the hospital.
Average Score
Total Score
Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)
IMS.1: Policies and procedures exist to meet the information needs of the care providers, management of the organization as
well as other agencies that require data and information from the Organization.
a The information needs of the

organization are identified and
are appropriate to the scope of
the services being provided by
the organization and the
complexity of the organization
104
Gap Analysis Report
Soni Hospital
b Policies and procedures to

meet the information needs are
documented.
c These policies and procedures
are in compliance with the
prevailing laws and
regulations.
d All information management
and technology acquisitions
are in accordance with the
policies and procedures.
e The organization contributes to

external databases in
accordance with the law and
regulations
Average Score
IMS.2: The organization has processes in place for effective management of data
a Formats for data collection are

standardized
b Necessary resources are
available for analyzing data.
105
Gap Analysis Report
Soni Hospital
c Documented procedures are

laid down for timely and
accurate dissemination of data
d Documented procedures exist
for storing and retrieving data
e Appropriate clinical and
managerial staff participates in
selecting, integrating and using
data.
Average Score
IMS.3: The organization has a complete and accurate medical record for every patient.
a Every medical record has a

unique identifier.
b Organization policy identifies
those authorized to make
entries in medical record.
c Every medical record entry is
dated and timed
d The author of the entry can be
identified
e The contents of medical record
are identified and documented
106
Gap Analysis Report
Soni Hospital
f The record provides an up-to-

date and chronological account
of patient care
a The medical record contains

information regarding reasons
for admission, diagnosis and
plan of care.
b Operative and other
procedures performed are
incorporated in the medical
record
c When patient is transferred to
another hospital, the medical
record contains the date of
transfer, the reason for the
transfer and the name of the
receiving hospital
d The medical record contains a
copy of the discharge note duly
signed by appropriate and
107
Gap Analysis Report
Soni Hospital
qualified personnel
e In case of death, the medical

record contains a copy of the
death certificate indicating the
cause, date and time of death.
f Whenever a clinical autopsy is
carried out, the medical record
contains a copy of the report of
the same.
g Care providers have access to
current and past medical
record.
Average Score
IMS.5: Policies and procedures are in place for maintaining confidentiality, integrity and
security of information.

procedures exist for
maintaining confidentiality,
security and integrity of
information
108
Gap Analysis Report
Soni Hospital
b Policies and procedures are in

consonance with the
applicable laws
c The policies and procedures
incorporate safeguarding of
data/ record against loss,
destruction and tampering
d The hospital has an effective
process of monitoring
compliance of the laid down
policy
e The hospital uses
developments in appropriate
technology for improving,
confidentiality, integrity and
security
f Privileged health information is
used for the purposes
identified or as required by law
and not disclosed without the
patient’s authorization
109
Gap Analysis Report
Soni Hospital
g A documented procedure
exists on how to respond to
patients/ physicians and other
public agencies requests for
access to information in the
medical record in accordance
with the local and national law.
Average Score
IMS.6: Policies and procedures exist for retention time of records, data and information.

procedures are in place on
retaining the patient’s clinical
records, data and information
b The policies and procedures
are in consonance with the
local and national laws and
regulations
c The retention process provides
expected confidentiality and
security
110
Gap Analysis Report
Soni Hospital
d The destruction of medical

records, data and information
is in accordance with the laid
down policy
Average Score
IMS.7: The organization regularly carries out review of medical records.
a The medical records are

reviewed periodically.
b The review uses a
representative sample based
on statistical principles.
c The review is conducted by
identified care providers.
d The review focuses on the
timeliness, legibility and
completeness of the medical
records
e The review process includes
records of both active and
discharged patients
f The review points out and
documents any deficiencies in
records
111
Gap Analysis Report
Soni Hospital
g Appropriate corrective and

preventive measures
undertaken are documented.
Average Score
Total Score
112
Gap Analysis Report
Soni Hospital
SECTION 6: SUMMARY OF SCORES OF VARIOUS CHAPTERS
S. NO. CHAPTER SCORE

1 Access, Assessment And Continuity Of Care (AAC)
2 Care Of Patients (COP)
3 Management Of Medication (MOM)
4 Patient Rights And Education (PRE)
5 Hospital Infection Control (HIC)
6 Continuous Quality Improvement (CQI)
7 Responsibilities Of Management (ROM)
8 Facility Management And Safety (FMS)
9 Human Resource Management (HRM)
10 Information Management System (IMS)
AVERAGE SCORE OF ALL CAHPTERS
113
Gap Analysis Report
Soni Hospital
SECTION 7: RESULT:
On the basis of detailed gap assessment on every standard and objective elements of NABH,
following conclusions can be derived.
1. Average score of the NABH standards (all chapters) is coming out to be 4.5 or 45%. This
score is much below the desirable value of >70% as per accreditation norms. Hence
rigorous efforts are required to be made to bring the score up from 45% to >70%
2. No chapters have scored 70% or more score individually. Thus there is a scope to improve
and strengthen the documentation and implementation in every chapter of NABH. Having
a score of 70% in every chapter, individually, is a must for accreditation
3. Compliance score of individual standards gives following quantum of deficiencies.
S. No. Chapter No. of standards with No. of standards with more than
average score less than one zero in its objective elements
5
1. Overall
2. AAC
3. COP
4. MOM
5. PRE
6. HIC
7. CQI
8. ROM
9. FMS
10. HRM
11. IMS
Note: It is mandatory for accreditation that no standard should have a score of less than 5 and no
standard can have more than one zero in its objective elements
114
Gap Analysis Report
Soni Hospital
ANNEX ‘A’.SIGNAGE & DISPLAYS
Specific signage requirements that shall be addressed in signage plan of the hospital are as given
below.
………………………………………………………………………………………..
…………………………………………………………………………………………………………………
…..
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………….
All signage and displays in the hospital shall be made in minimum two languages and a symbolic
representation. The two languages shall be ‘English’ and ‘Hindi’. The dimensions of all signage and
displays shall be kept such that it should be clearly visible from distance
115
Gap Analysis Report
Soni Hospital
ANNEX ‘B’ – Physical Safety Requirements
Following physical safety aspects shall be taken care in the hospital
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………
116

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H o s p ita l & H e a lt h C a r e C o n s u lta n ts

GAP ANALYSIS REPORT

Astron Hospital and Health Care Consultants Pvt. Ltd.

Publication, reproduction, photocopying, storage, or transmission

Consultants Pvt. Ltd., New Delhi

Consultants Pvt. Ltd., New Delhi

Our heartfelt thanks to ………………………………….and the Governing Board members enabling

We are highly thankful to,…………………………………………… for providing us a platform to

We are profoundly grateful to,…………………………………………………… who has been very

We would like to thank, …………………………………………Medical Supdt, who has been

Astron Hospital and Health Care Consultants Pvt. Ltd.

Consultants Pvt. Ltd., New Delhi

Section No Topic Page Number

Consultants Pvt. Ltd., New Delhi

Consultants Pvt. Ltd., New Delhi

SECTION 2. ORGANISATION OF REPORT

Consultants Pvt. Ltd., New Delhi

SECTION 3. HOSPITAL PROFILE

S. No. Particulars Details

Consultants Pvt. Ltd., New Delhi

Specialties Number of specialist (full time) Number of specialist (visiting /

Consultants Pvt. Ltd., New Delhi

S. No. Particulars Details

Consultants Pvt. Ltd., New Delhi

S. No. Designation of ICU Number of beds per Number of

S. No. Designation of Operation theatre (Major and Number

Consultants Pvt. Ltd., New Delhi

HOSPITAL HUMAN RESOURCE

Staff category On hospital pay roll Contractual

Nursing Staff (category wise)

Technical Staff (category wise)

Medical administration (category

Consultants Pvt. Ltd., New Delhi

Senior Administrative Staff

General administration (category

Housekeeping and security staff

DETAILS OF DIAGNOSTIC SERVICES

Consultants Pvt. Ltd., New Delhi

Imaging Sciences (Please list scope of services)

S. Service category Available / Not available

S. Administrative departments (please list)

Consultants Pvt. Ltd., New Delhi

7. OPD, Reception & Enquiries

S. Outsourced services (please list)

Consultants Pvt. Ltd., New Delhi

WORK LOAD DETAILS (of the current quarter)

SECTION 4. PHYSICAL STRUCTURE REQUIREMENTS

Consultants Pvt. Ltd., New Delhi

Consultants Pvt. Ltd., New Delhi

S. No. Department and observations Desirabilit Priority

Consultants Pvt. Ltd., New Delhi

S. No. Department and observations Desirabilit Priority

Consultants Pvt. Ltd., New Delhi

SECTION 5: GAP ASSESSMENT AS PER NABH STANDARDS

Elements Observation Scores Recommendations

a The services being provided are

c The staff is oriented to these

Consultants Pvt. Ltd., New Delhi

a. Standardized policies and

b. The policies and procedures

c. Patients are accepted only if the

d. The policies and procedures also

e. The staff is aware of these